Healthcare Provider Details

I. General information

NPI: 1053585299
Provider Name (Legal Business Name): SUSAN M ZOLL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN Z GRUBBS RD

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 KINGSLEY LN
NORFOLK VA
23505-4602
US

IV. Provider business mailing address

150 KINGSLEY LN
NORFOLK VA
23505-4602
US

V. Phone/Fax

Practice location:
  • Phone: 757-889-4726
  • Fax: 757-889-5399
Mailing address:
  • Phone: 757-889-4726
  • Fax: 757-889-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number555875
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: